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General NPI Number Information
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NPI Number | 1750622072
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Entity Type | Organization
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Legal Business Name | ORTHODENTAL PC
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Dates
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Enumeration Date | 03/12/2013
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Last Update Date | 03/12/2013
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Provider Practice Location Address
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Address Line | 1748 W MALONEY AVE
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City | GALLUP
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State | NM
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Zip | 87301-3333
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Country | US
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Telephone | 505-863-8100
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Fax | 505-863-8064
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Provider Business Mailing Address
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Address Line | 1748 W MALONEY AVE
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City | GALLUP
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State | NM
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Zip | 87301-3333
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Country | US
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Telephone | 505-863-8100
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Fax | 505-863-8064
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Authorized Official
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Title or Position | OWNER
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Name | JOSEPH A WILSON
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Credential | DMD, MSD
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Telephone | 505-325-8858
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | DD3399
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DD3399
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License Number State | NM
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